A Case of Sick Sinus Syndrome Presenting As Exploding Head Syndrome
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CASE REPORT online © ML Comm J Korean Sleep Res Soc 2012;9:61-63 ISSN 1738-608X A Case of Sick Sinus Syndrome Presenting as Exploding Head Syndrome Hye Yun Kim, Do Young Yoon, Dong Sun Kim, Ji Sun Kwon and Hyun Jeong Han Department of Neurology, Myongji Hospital, Kwandong University College of Medicine, Goyang, Korea Received December 3, 2012 Exploding head syndrome (EHS) is a rare syndrome experienced with explosive noise happening in a head. Revised December 24, 2012 A 78 year old man visited for intractable headache with explosive noises. His vieo-electroencephalography Accepted December 24, 2012 monitoring showed tachy-brady arrhythmia on electrocardiogram. We diagnosed as a sick sinus syndrome Address for correspondence (SSS) presented with EHS. We suggest SSS should be considered with the elderly patients who have EHS Hyun Jeong Han, MD, PhD Department of Neurology, symptom. Myongji Hospital, Kwandong J Korean Sleep Res Soc 2012;9:61-63 University College of Medicine, 697-24 Hawjeong-dong, Key Words: Sick sinus syndrome, Headache. Deogyang-gu, Goyang 412-270, Korea Tel: +82-31-810-5403 Fax: +82-31-969-0500 E-mail: [email protected] Exploding head syndrome (EHS), which is a rare primary night before bed time. headache syndrome is characterized with explosive noise hap- His blood pressure was 130/75 mm Hg and there was not sig- pening in a head.1 EHS was first described as the syndrome of nificant finding on results of routine serologic and cardiologic ‘snapping of the brain,’ by Armstron-Jones in 1920. In 1988, studies including electrocardiogram (ECG). Also on the re- Pearce reported 50 patients with EHS. The cluster attacks, sult of brain magnetic resonance imaging, there were no sig- happening at night time over weeks, followed by prolonged nificant lesions and no abnormality of arterial nor venous stu- remissions.1 Patients with EHS described variously as ‘loud dies on the angiography. To rule out seizure episode, video- bang’, ‘short gun’ or ‘bomb-like explosions’.2 sEHS i more af- electroencephalogram (EEG) monitoring with ECG was per- fected commonly in women than men and older than 50 years formed from the evening to the next morning. During the old. video EEG monitoring, there was no significant finding, how- ever, it was shown a tachy-brady arrhythmia accompanying Case Report with the headache attack on the ECG (Fig. 1). In detail, the pa- tient was awake but calmly lying down during having tachy- A8 7 year old man visited our neurology clinic for intrac- brady arrhythmia and sinus pause on the ECG. In the middle table headache, which persisted for 2 months. He had no per- of pause was presenting, the patient took action to sit up and tinent medical history such as hypertension, cardiac disease was complaining having noise attack from just before. We can or diabetes mellitus. He described his symptoms as sudden mark the point of the attack started and assume the point was attacks with big noise in his head like a bomb explosion and at several seconds after sinus pause. persisting headache for half or one hour. The location of pain Though detail cardiologic evaluations, he was diagnosed was mainly vertex area with moderate to severe intensity. The with sick sinus syndrome (SSS) and the pain attack gradually dis- patient said that the character of pain cannot be explained by appeared with insertion of pacemaker. a simple word and often experienced almost loss of conscious- ness with the pain. The pain attack was not controlled by pain Discussion medication and occurred two or three times a day, mainly in the evening or at night. The attacks were aggravated at Sick sinus syndrome is a condition, which involves sinus Copyright © 2012 Korean Sleep Research Society 61 A Case of Sick Sinus Syndrome Presenting as Exploding Head Syndrome Fig. 1. Video EEG monitoring. ECG during video EEG monitoring showed tachy-brady arrhythmia (arrow). EEG: electroencephalogram, ECG: electrocardiogram. node dysfunction, and commonly affects elderly patients.3 SSS formed a 24 hours Holter monitoring to diagnose of SSS. The has multiple manifestations on ECG, such as sinus bradycar- patient was inserted pacemaker and did not experience the dia, sinus arrest, sinoatrial block, and alternative bradycardia symptom that he complained of before. and tachycardia, called bradycardia- tachycardia syndrome, Exploding head syndrome is not well known to physicians. which was present in the patient.4 The causative etiology is also not understood well.7 The pos- Patients with SSS are often asymptomatic or nonspecific. sible mechanisms have been suggested the result of a sudden Symptoms are thought to be the result from decreased cardiac movement of a middle ear component of the eustachian tube output, during arrhythmic attacks.5 Therefore, most patients and minor seizure in temporal lobe.7 To correct diagnosis, with SSS sometimes showed presyncope or syncope, as a re- we should rule out the other diagnosis which can have simi- sult of cerebral hypoperfusion. Other symptoms include wa- lar symptoms such as thunderclap headache, hypnic head- kefulness during night, memory loss, errors in judgement, ache, nocturnal paroxysmal hemicrania, low volume sub- lethargy and lightheadedness.3,6 In the case, there is no signi- arachnoid hemorrhage and nocturnal epilepsy.8 Therefore, ficant finding on screening ECG and no other significant the patients with EHS need to perform brain images or EEG. symptom which can be presented a cardiologic disease. The The loud noises, which EHS patients can have, might also be patient only explained the experience of explosive nose in his a common symptom in SSS. On another similarity is the range head and persistent headache. The symptom corresponded of frequent affected age between EHS and SSS. With that, we with EHS and he was diagnosed as a EHS ruled out of other suggest adding SSS as another differential diagnosis of EHS cardiologic issues. especially in elderly patients with or without risk factors of The diagnosis of SSS might be difficult because the symp- cardiac problems. toms are variety or asymptomatic. Therefore, many patients with SSS are often ruled out of other diseases, like as happen- REFERENCES ing in this case. Some elderly patients with SSS often misdiag- 1. Pearce JM. Exploding head syndrome. Lancet 1988;2:270-271. nosed as a senile dementia presenting with gradual loss of me- 2. Casucci G, d’Onofrio F, Torelli P. Rare primary headaches: clinical in- 6 sights. Neurol Sci 2004;25 Suppl 3:S77-S83. mory. 3. Brignole M. Sick sinus syndrome. Clin Geriatr Med 2002;18:211-227. Through a 24 hour Holter monitoring detecting cardiac ar- 4. Colquhoun M. When should you suspect sick sinus syndrome? Practi- rhythmia is needed for a proper diagnosis of SSS. There are tioner 1999;243:422-425. 5. Durham D, Worthley LI. Cardiac arrhythmias: diagnosis and manage- many other methods to diagnosis SSS such as isometric hand ment. The bradycardias. Crit Care Resusc 2002;4:54-60. grip exercise, carotid massage or Valsalva’s maneuvers under- 6. Wozakowska-Kapłon B, Opolski G, Kosior D, Jaskulska-Niedziela E, going ECG monitoring.5 In this case, the patient was per- Maroszyn´ska-Dmoch E, Włosowicz M. Cognitive disorders in elderly 62 Kim HY et al. patients with permanent atrial fibrillation. Kardiol Pol 2009;67:487- 2001;5:279-280. 493. 8. Sachs C, Svanborg E. The exploding head syndrome: polysomnographic 7. Green MW. The exploding head syndrome. Curr Pain Headache Rep recordings and therapeutic suggestions. Sleep 1991;14:263-266. www.sleepnet.or.kr 63.